Revascularization vs. Deferral of Physiologically Significant Lesions in the Left Main Coronary Artery

Most randomized studies on decision-making in coronary artery disease revascularization exclude left main coronary artery disease (LMCAD), as did the ISCHEMIA Study. On the other hand, the benefits of functionally assessing lesions, proven in studies such as FAME, emphasize the importance of this tool in guiding revascularization decisions. However, there is still little understanding of clinical outcomes in patients with stable coronary artery disease and LMCAD with demonstrated ischemia.

Revascularización vs diferir lesiones fisiológicamente significativas del tronco de coronaria izquierda

The aim of this multicenter registry was to evaluate the long-term clinical outcomes of physiologically significant LMCA lesions (iFR ≤0.89) with revascularization versus medical treatment.

The primary endpoint (PEP) was the rate of major adverse cardiovascular events (MACE), including a combination of death, non-fatal acute myocardial infarction (AMI), and ischemia-driven revascularization of the treated LMCA lesion. The secondary endpoint (SEP) included cardiac death, LMCAD-related AMI, and ischemia-driven revascularization of the treated LMCA lesion.

The analysis included a total of 225 patients, with 151 assigned to the revascularization group and 74 to the deferred treatment group. The mean age was 68 years, and most subjects were male. The average SYNTAX score was 22, and the mean instantaneous wave-free ratio (IFR) value was 0.83. According to quantitative angiography, the percentage of stenosis was approximately 45%. Propensity score matching was subsequently applied to homogenize the samples. The most common LMCA lesion was in its distal third in around 80% of patients. The mean follow-up was 2.8 years.

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Regarding the PEP, the MACE rate was 28.4% in the deferred treatment group and 14.9% in the revascularization group (hazard ratio [HR]: 0.42 [95% confidence interval [CI], 0.20–0.89]; P=0.023). In relation to the SEP, cardiac death and LMCAD-related AMI occurred significantly less in the revascularization group (0.0% versus 8.1%; P=0.004). The rate of ischemia-driven revascularization of the treated LMCA lesion was significantly lower in the revascularization group (5.4% vs. 17.6%; HR: 0.20 [95% CI, 0.056–0.70]; P=0.012).


In conclusion, in patients with LMCAD and physiologically significant lesions, revascularization, compared with a conservative strategy, was associated with a significant reduction in long-term MACE, including cardiac death, LMCAD-related AMI, and revascularization of the treated lesion.

Dr. Andrés Rodríguez.
Member of the Editorial Board of

Original Title: Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance.

Reference: Takayuki Warisawa MD et al Circ Cardiovasc Interv. 2023;16:e012700.

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